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End Stage Renal Disease (ESRD)
Annual Compliance Education
This course contains annual compliance
education necessary to meet
compliance and regulatory
requirements.
Instructions:
To receive credit for completion:
1. Read the content in full.
2. Complete the online exam.
Last Revised: 06/05/15
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End Stage Renal Disease (ESRD)
Welcome
Purpose:
To educate all clinical areas about the care and considerations of End Stage Renal
Disease in the adult patient.
Learning Objectives:
When finished with this course, you should be able to:
• Define End Stage Renal Disease (ESRD)
• Describe three treatments for ESRD
• Describe special considerations related to the care of the patient with ESRD
• State how to access the policies related to ESRD
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Defining End Stage Renal Disease (ESRD)
Chronic kidney disease (CKD), the precursor to End Stage Renal Disease (ESRD), is a
progressive, irreversible loss in kidney function over a period of months or years. The
stages of CKD kidney loss is based on a person’s Glomerular Filtration Rate (GFR). The
GFR is how much blood passes through the tiny filters of the kidneys per minute.
Stage Description
GFR Level
Normal Kidney Function
Healthy kidneys 90 ml/min or more
CKD Stage 1
Kidney damage with normal or high GFR 90 ml/min or more
CKD Stage 2
Kidney damage and mild decrease in GFR 60-89 ml/min
CKD Stage 3
Moderate decrease in GFR 30-59 ml/min
CKD Stage 4
Severe decrease in GFR 15-29 ml/min
CKD Stage 5 or ESRD
Kidney failure less than 15 ml/min or on dialysis
•
The treatment for ESRD is hemodialysis, peritoneal dialysis or a renal (kidney)
transplant
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Kidneys Role in Maintaining Health
Kidneys play a critical role in maintaining health. They:
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Eliminate waste products through an internal blood filtering system
Regulate blood formation and red blood cell production
Regulate blood pressure
Control the body’s delicate chemical and fluid balance
Produce Erythropoietin (EPO), which stimulates the bone marrow to make red
blood cells
Produce renin, which regulates blood pressure through electrolyte and water
balance
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Signs and Symptoms of ESRD
Common signs and symptoms of ESRD include:
Anorexia
Anemia
Generalized
Weakness
Bleeding
Tendencies
Mental
Confusion
Fatigue
Nausea/Vomitin
g
Hypertension
Thirst
Electrolyte
Imbalances
Uremic Frost
(powdery look on
skin)
Edema
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Dietary Considerations
There are numerous dietary concerns for the
adult patient with ESRD:
• Protein to maintain nitrogen balance
• Calories to maintain or reach ideal weight
• Fluid balance
• Sodium, Potassium and Phosphorous intake
A Renal Dietician
can help create a
meal plan that
contains the correct
amounts and types
of food to meet
individual needs
All ESRD patients MUST have a nutritional screen on
admission.
A consult is triggered when an ESRD patient is indicated in
the Electronic Medical Record (EMR).
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
ESRD Diets
There are two diets that can be ordered for an ESRD adult patient.
Available in Canopy
Renal Dialysis Diet
This diet is typically for the
patient currently on chronic
hemodialysis.
Renal CKD Diet
This diet is typically
appropriate for patients in
CKD stages one through four.
The CKD diet is more restrictive
than a dialysis diet.
The goal of the diet for hemodialysis is to maintain optimal nutrition while limiting the
buildup of waste products between hemodialysis treatments.
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Common Medications
Scheduled medications, including
antihypertensives, should be given as ordered.
Medications should not be held prior to dialysis
without a Physician’s order.
Typical medications for the patient with ESRD
include:
• Antihypertensives
• Vitamin D supplements such as Rocaltrol,
Hectorol or Calcitriol
• Epogen (Procrit)
• Vitamins and minerals
• Iron supplements
• Antibiotics
• Laxatives, Stool softeners
• Atarax or Benadryl for itching
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Complications for Patients with ESRD
Monitor your
ESRD patients
for
complications
Monitor for the following:
Hypertension
Chest pain
Hypotension
Seizures
Edema
Air embolism (air bubble trapped in
Pulmonary edema (fluid in the
blood vessels)
lungs)
Hemolysis
Hyperkalemia (high potassium
Bleeding
level)
Clotting of access devices
Hypokalemia (low potassium level)
Nausea/Vomiting
Infection
Muscle cramps
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Common Medications (continued)
• Phosphate binders such as Renegal, Renvela and Phoslo
- These medications MUST be taken with food
- Binders will be given as scheduled and documented by the dialysis nurse while patient is in
the kidney dialysis unit (KDU)
- Floor nurse should not “reschedule” on the Electronic Medical Administration Record
(eMAR) to allow dialysis nurse to document
- Phosphate binders do not have to be sent to the dialysis unit with the patient (KDU has
stock)
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Nursing Considerations Related to ESRD
Nursing Considerations for patients with ESRD:
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•
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•
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Vital signs
Strict I/O
Diet restrictions
Fluid restrictions
Activity level
Skin care
Accurate daily weight
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•
•
Electrolyte balance
Changes in patient
condition
Patient Care Plan
(developed by ESRD
Multidisciplinary Team)
Policies related to ESRD and patients receiving hemodialysis are found on
PeopleConnect:
PeopleConnect
Facilities CHS BR
Policies
Policy Tech
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Hemodialysis
Hemodialysis uses a special filter called a dialyzer that
functions as an artificial kidney. During treatment, blood
travels through tubes into the dialyzer which filters out wastes
and extra fluids.
• Most hemodialysis patients go to dialysis three times per
week
• Three forms of hemodialysis access devices are:
1. Arteriovenous fistula (permanent access option)
2. Arteriovenous graft (permanent access option)
3. Hemodialysis catheters (temporary access option)
Hemodialysis access devices are the patients’ lifeline and
must be protected and monitored closely.
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Ateriovenous Fistula & Graft Diagrams
Arteriovenous Fistula (AVF))
Arteriovenous Graft (AVG)
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Ateriovenous Fistula & Graft
Comparing Arteriovenous Fistula and Graft:
Arteriovenous Fistula
Arteriovenous Graft
Patient’s own artery and vein are surgically
connected. No artificial material is used.
Artificial material that is attached to the
patient’s blood vessels
Found in upper or lower arm
Usually found in upper or lower arm. May be in
the thigh or chest.
Healing time is longer for a fistula than a graft
Two to three weeks healing time
One incision
Two incisions
Considered the BEST vascular access for
patients on dialysis
Considered the second best vascular access
for patients on dialysis
Lasts longer than AVG (lasts many years)
Does not last as long as AVF and has a higher
risk of clotting
Healing time longer
Can access earlier
Least risk of infection in comparison to any
other dialysis access
Lower risk of infection in comparison to
hemodialysis catheters
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Nursing Considerations Related to Fistulas & Grafts
Considerations for Fistulas and Grafts are:
• Encourage new fistula patients to perform daily exercises by squeezing a ball or
rolled up sock (four to five times per day for five to 10 minutes). Daily exercises will
provide growth of the fistula.
• Examine site, palpate for thrill, auscultate for bruit and document findings
• Avoid blood pressures or IV sticks of affected arm with AFV or AVG
- A sign should be posted above the patient’s bed stating:
“No IVs, BPs or lab draws on _________________ arm.”
• Instruct patient to avoid sleeping on affected arm
• Avoid hypotensive episodes which can cause the access to clot
• Maintain dressing on access site after hemodialysis for three to four hours
• Refer to the Care of the Patient Post Hemodialysis Policy
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Hemodialysis Catheters
Hemodialysis catheters are often used when patients need dialysis immediately or when
patients have no other access alternatives.
• Hemodialysis catheters are inserted into the jugular, subclavian or femoral vein
• The catheter ports are color-coded (red and blue) for accessing the hemodialysis system
All Catheters:
• Not ideal as permanent access
• High infection rates often resulting in serious
complications such as sepsis, endocarditis and
death
• Difficult to obtain sufficient blood draw for dialysis
• Less efficient dialysis treatment
• Swimming and showering not allowed
Hospitalizations, infections and death increase by
50% in patients with catheters compared to those with
an AFG or AVG.
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Temporary & Permanent Hemodialysis Catheters
Comparing Temporary and Permanent Hemodialysis Catheters:
Temporary Hemodialysis Catheter
Permanent Hemodialysis Catheter
Usually stays in one to three weeks
Can stay in longer than one year
Nurse can remove with a physician’s order
Only radiology can remove
Three types:
1. Flexible double lumen (light blue hub)
2. Rigid double lumen (teal hub): Strict bed
rest if patient has rigid catheter
3. Triple lumen catheter with medical port
that can be used like a regular central line
Double lumen (typically white colored hub)
Located at chest or femoral site
Located at chest site and occasionally at
femoral site
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Nursing Considerations Related to Hemodialysis Catheters
• Access policies related to hemodialysis catheters via the hospital computer using
the following pathway:
People
Connect
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Facilities –
CHS BR
Policies
Policy Tech
Only dialysis nurses or trained nurses are allowed to access the dialysis catheter
Gain a Nephrologist order before accessing hemodialysis catheters for blood
draws or administration of medications (required)
Use a strict aseptic technique when accessing devices. Review policy prior to
accessing.
It is important to withdraw the heparin from the catheter prior to accessing
Do not get the catheters wet. They can become easily infected.
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Peritoneal Dialysis
Peritoneal Dialysis (PD) uses the peritoneal membrane as a filter to remove wastes and
excess fluids from the blood.
• The PD catheter is used for peritoneal dialysis to instill and remove fluids
For all peritoneal dialysis patients:
The PD catheter is never access without
an order from the Nephrologist and can
only be done by a trained peritoneal
nurse.
This includes accessing the
catheter for peritoneal fluid samples or
cultures.
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Nursing Considerations Related to Peritoneal Dialysis
• Only PD trained nurses can perform PD
• NEVER move or unplug the PD machine, even when
the patient is not being dialyzed
• Place the patient in a private room
• Never use scissors near the tenckoff catheter and
tugging on the catheter should be avoided
• Encourage patients to wash their catheter site daily or
every other day with antibacterial soap, once healed
• Consult with a dietician to confirm the same renal diet
and fluid restriction the patient was on at home is
ordered while inpatient
Daily Assessments:
Fluid balance
Weight
Blood pressure
Lung sounds
Edema
Electrolyte
imbalance, such as
hypokalemia
Bowel function
(constipation can cause
problems in the dialysis
process)
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Renal Transplants
Renal Transplant patients:
• Are provided a functioning kidney from either a living or deceased donor to
someone with ESRD
• Are not cured by the renal transplant
• Must take medications for the rest of their lives to prevent rejection of the organ
Common Medications for Renal Transplant
Patients
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Immunosuppressants
- Prograf (Tacrolimus)
- Prednisone
- Cellcept or Myfortic
- Sirolimus
- Cylclosporin
Antihypertensives
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Nursing Considerations Related to Renal Transplant Patients
During transplant surgery, the patient receives IV “induction therapy” (a strong
immunosuppressant medication)
• Prograf is one of the immunosuppressants given
to prevent rejection of the kidney
• These medications should be given at specific
A patient will typically be on
a combination of
immunosuppressant
medications
times
• Prograf levels must be drawn prior to the AM
dose unless otherwise ordered
• Grapefruit juice affects absorption of
immunosuppressants, such as Prograf, and
must be avoided
• Any disruption or change in medication
delivery can put the patient at risk for rejection
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Nursing Considerations Related to Renal Transplant Patients (continued)
• Standard Precautions and Protective Environment
Precautions should be used, including:
- Strict hand hygiene
- Strict ureteral catheter care and maintenance
- Strict central line care and maintenance
• Elevated temperature (100.5) can indicate infection
or rejection and must be monitored
• A decrease in urine output can indicate rejection or
graft dysfunction and must be monitored
• Accurate daily weights must be taken
• Regular diet, without restrictions, can be followed unless
otherwise ordered
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
ESRD Patient Education
ESRD Patient Education at CMC
ESRD New Patient
Educational
Manual
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Educational
Magnet
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All patients that are newly diagnosed with ESRD are provided a manual
The manual can be found electronically on Careline (CMCC – patient
instructions – ESRD PT Educational Manual)
A nursing order can be entered under “ESRD new patient education”
Patients that have hemodialysis catheters placed receive an
educational magnet titled “Caring for you Short Term Catheter”
The magnet is given with catheter placement in radiology or with
treatment in KDU
Hemodialysis
Access Education
•
KDU nurses educate new hemodialysis patients on the importance of
obtaining a fistula or graft and how to care for their catheter until a
permanent access is obtained
ESRD Link
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A telephone-based self-management program for patients that:
- Are frequently readmitted (in less than 30-90 days of prior
admission)
- Lack a support system
- Are medically non-compliant
ESRD Support
Group
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Support group for patients and families
The Social Worker educates patients receiving dialysis about this group
opportunity
ANNUAL COMPLIANCE EDUCATION
End Stage Renal Disease (ESRD): Job Aid
Purpose: Use this job aid as a guide for the care of patients with ESRD.
• Chronic Kidney Disease (CKD) is classified into 5 stages based on a person’s estimated GFR. CKD
Stage 5 is End Stage Renal Disease (ESRD).
• ESRD is the loss of function in both kidneys and is irreversible
• The three treatments for ESRD are hemodialysis, peritoneal dialysis or a renal transplant
• Patients on dialysis should be on a dialysis diet unless otherwise ordered by their Nephrologist
• On admission, all patients with ESRD must have a Nutritional and Medical Social Work screening
• Nursing considerations for the patient with ESRD include strict standard precautions, I/O, daily
weights and monitoring electrolyte balance
• Beds must be zeroed on admission for accurate weights
• Policies related to ESRD, including accessing the hemodialysis catheter, are located on
PeopleConnect
• Only PD trained nurses are to perform peritoneal dialysis
• Immunosuppressant medications for renal transplant patients are taken at specific times. Any
disruption in delivery puts the patient at risk for rejection.
ANNUAL COMPLIANCE EDUCATION
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End Stage Renal Disease (ESRD)
Summary
End Stage Renal Disease involves progressive, irreversible destruction of both kidneys.
This course discussed the considerations, treatments and procedures for ESRD, such as
hemodialysis, peritoneal dialysis and renal (kidney) transplant.
The following are some strategies reviewed in this course:
• Define End Stage Renal Disease (ESRD)
• Describe three treatments for ESRD
• Describe special considerations related to the care of the patient with ESRD
• State how to access the policies related to ESRD
ANNUAL COMPLIANCE EDUCATION